Provider Demographics
NPI:1245682202
Name:BASICH, CRYSTAL LYNNE III (DPT)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:LYNNE
Last Name:BASICH
Suffix:III
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7923 MUNSON RD
Mailing Address - Street 2:STE 6
Mailing Address - City:MENTOR ON THE LAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44060-3742
Mailing Address - Country:US
Mailing Address - Phone:440-209-1836
Mailing Address - Fax:
Practice Address - Street 1:2899 HUBBARD RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:OH
Practice Address - Zip Code:44057-2933
Practice Address - Country:US
Practice Address - Phone:440-428-0422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-01
Last Update Date:2016-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH012276225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0747777Medicaid
OH0747777Medicaid